Provider Credentialing: A Complete Guide

The importance of provider credentialing is underscored by the fact that it creates new avenues for income generation, such as when a physician with a credential receives more patient referrals from payers. Credentialing services for providers also guarantees that the patient is receiving care from a reputable practitioner.

Provider Credentialing: What Is It?

A health insurance carrier will formally evaluate a provider’s credentials and competency based on demonstrated competence through the provider credentialing procedure. It can take up to three months to complete this laborious operation. The requirement for submitting a lot of background information is what’s behind the drawn-out procedure. The medical billing company works for may also need to undergo certification, depending on the situation.

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Criteria for credentialing:

  • Has an unrestricted license
  • Any disciplinary actions or sanctions by insurers, hospitals, licensing boards, or professional organizations
  • Presence of any criminal history
  • Is the Provider certified by the medical board?
  • General health status

The credentialing procedure is confirmed if a doctor meets requirements for providing clinical care, and it typically takes 60 to 120 days for a payer to get certified.

While the certification procedure is ongoing, some providers have concerns that “During the credentialing process, are they able to work?

The response to the earlier query is “No”. Before starting to work, a healthcare provider must wait for the credentialing procedure to be finished and approved.

This guarantees that every patient will always receive care from qualified and experienced specialists to address their healthcare needs.

Any organization that hires people without credentials, even if they are in the process of obtaining them, runs a legal risk.

Following are some checklist for accurate application of hurdle-free credentialing process:

  • Provider start date in practice
  • Copy of state license
  • Copy of DEA
  • Provider DOB and SSN
  • NPI Number
  • Updated CV- work history
  • NPPES logons
  • CAQH logons
  • Malpractice incidence details
  • Copy of Degree/Diploma certificates
  • Copy of Driving License
  • Group Name
  • GNPI & Tax id
  • Practice and billing address along with Phone and Fax #
  • Signed W-9 Form

Role of CAQH in Provider credentialing

One of the most popular Web services for credentialing is provided by the Center for Affordable Quality Healthcare, Inc. (CAQH). The Universal Provider Data source (UPD), a database provided by CAQH, compiles all the data necessary for credentialing and makes it accessible to third-party payers online.

There are three steps to getting set up in CAQH:

  • Obtain your CAQH ID (within 2-3 business days)
  • Set up your secure username and password
  • Complete the online application and send in the required documentation
  • Send your attestation for signature, which certifies the application
  • Grant insurance companies access to your online application

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Your enrollment with the insurance companies will be delayed if your CAQH application is not finished and up to date. Additionally, you won’t be paid for your services in this case.

In general, the procedure can take a few days to a few weeks. It may differ according on the field in which you are seeking credentials, the CVO you are utilizing, and if you have submitted all required documentation and completed the application properly.

It is therefore typically ideal to start the application procedure 90 days before to your start date at a new facility. Ninety days gives the CVO some wiggle room in case verification entities don’t reply to requests right away or the CVO needs to look into discrepancies for clarity.



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